Enteral and parenteral nutrition in cancer patients, a comparison of complication rates: an updated systematic review and (cumulative) meta-analysis

Cancer-Related Malnutrition and the Role of Parenteral Nutrition in Cancer; A Narrative Review

The growing incidence rate of cancer and its associated morbidity and mortality prompts the need to identify factors that could improve the quality of life (QoL) and survival of a patient with cancer. Cancer-associated malnutrition is a common complication that could start at the early stages of cancer and could further develop into advanced cachexia. Response to treatment, length of hospital stay, progression of infection, and other complications of cancer including chemotherapy adverse events could all be influenced by the progression of malnutrition. Nutritional interventions may vary from oral to enteral and parenteral therapy. Parenteral nutrition (PN) therapy may benefit patients at certain stages of cancer in whom contraindications or inefficacy of other modalities of nutritional support are present. This method may seem invasive, costly, and risky but at the same time may improve certain patients' QoL and chance of survival. In trained settings with proper facilities, this method of nutritional support can benefit patients; However, the indication for starting PN must be carefully supervised considering that other nutritional support methods may be equally efficient and at the same time easier to access and apply.

SEOM clinical guidelines for cancer anorexia-cachexia syndrome (2023)

Cancer-related anorexia-cachexia syndrome (CACS) is a debilitating condition afflicting up to 80% of advanced-stage cancer patients. Characterized by progressive weight loss, muscle wasting, and metabolic abnormalities, CACS significantly compromises patients' quality of life and treatment outcomes. This comprehensive review navigates through its intricate physiopathology, elucidating its stages and diagnostic methodologies. CACS manifests in three distinct stages: pre-cachexia, established cachexia, and refractory cachexia. Early detection is pivotal for effective intervention and is facilitated by screening tools, complemented by nutritional assessments and professional evaluations. The diagnostic process unravels the complex interplay of metabolic dysregulation and tumor-induced factors contributing to CACS. Management strategies, tailored to individual patient profiles, encompass a spectrum of nutritional interventions. These include dietary counseling, oral nutritional supplements, and, when necessary, enteral nutrition and a judicious use of parenteral nutrition. Specific recommendations for caloric intake, protein requirements, and essential nutrients address the unique challenges posed by CACS. While pharmacological agents like megestrol acetate may be considered, their use requires careful evaluation of potential risks. At its core, this review underscores the imperative for a holistic and personalized approach to managing CACS, integrating nutritional interventions and pharmacological strategies based on a nuanced understanding of patient's condition.

Is monitoring of gastric residual volume for critically ill patients with enteral nutrition necessary? A meta-analysis and systematic review

BACKGROUND

There are many controversies over the necessity of monitoring gastric residual volume in the nursing care of enteral nutrition. We aimed to conduct an updated meta-analysis to evaluate the effects of monitoring or not monitoring gastric residual volume on patients' outcomes and complications.

METHODS

We searched the Cochrane Library database to 15 April 2021 for randomized controlled trials (RCTs) on the effects of gastric residual volume and no gastric residual volume monitoring. Review Manager software was used for data analysis.

RESULTS

A total of seven RCTs involving 1240 enteral nutrition patients were included. Gastric residual volume monitoring was associated with reduced incidence of vomiting (OR2.33, 95% CI:1.68-3.24), whereas no gastric residual volume monitoring was associated with reduced incidence of unnecessary interruptions of enteral nutrition (OR0.38,95% CI:0.26-0.55). There were no significant differences on the incidence of abdominal distention (OR1.87, 95% CI:0.82-4.28), diarrhoea (OR1.03,95% CI:0.74-1.43), VAP (OR0.83, 95%CI:0.37-1.89), duration of mechanical ventilation (MD -0.06,95% CI:-1.22-1.10), length of ICU stay (MD -1.33, 95% CI:-3.58-0.91) and mortality (OR0.90,95% CI:0.61-1.34).

CONCLUSIONS

Not monitoring gastric residual volume is associated with reduced unnecessary interruptions of enteral nutrition related to inadequate feeding and increased risk of vomiting.

Influence of Enteral Nutrition on Quality of Life in Head and Neck Cancer and Upper Gastrointestinal Tract Cancer Patients within a Pair-Matched Sample

Patients with cancers of the head and neck and upper gastrointestinal tract are particularly susceptible to malnutrition, which worsens both their prognosis and quality of life and may result in the need for enteral or parenteral nutrition. The aim of this study was to investigate the impact of enteral nutrition on the quality of life in a paired sample. This study included 50 patients with cancer in two paired subgroups: with enteral nutrition (studied group) and without enteral nutrition (matched group). This study was based on self-reports collected with the EORTC QLQ C30 questionnaire and retrospective analysis of medical records. The analysis revealed that weight loss, group type, and age were the primary factors influencing patients' quality of life. Compared with all cancer patients and the general Polish population, the scores of patients in both groups were below reference values for functional scales and exceeded reference values or were similar for fatigue and vomiting/nausea. Patients who received enteral nutrition more frequently scored lower on the functional scales and higher on the symptomatic scales than the control group. These findings emphasize the complex relationship between cancer, nutritional status, and quality of life.

The Critical Exploration into Current Evidence behind the Role of the Nutritional Support in Adult Patients Who Undergo Haematogenic Stem Cell Transplantation

Haematopoietic stem cell transplantation (HSCT) is a treatment option for many haematological conditions in patients of all ages. Nutritional support is important at each stage of treatment, but particular nutritional needs and dictated support occur during the preparatory (conditioning regimen) and post-transplant periods. Patients may require nutritional treatment by the enteral or parenteral route. The quantitative and qualitative composition of meals may change. Vitamin requirements, including vitamin D and vitamin C, might also be different. An adequately composed diet, adapted to the needs of the patient, may influence the occurrence of complications such as graft-versus-host disease (GvHD), gastrointestinal disorders, infections, and reduced survival time. Haematological diseases as well as transplantation can negatively affect the intestinal flora, with negative consequences in the form of mucosal inflammation and disorders of a functional nature. Currently, aspects related to nutrition are crucial in the care of patients after HSCT, and numerous studies, including randomized trials on these aspects, are being conducted. This study serves the critical analysis of current scientific evidence regarding nutritional support for patients after HSCT.

Central Line-Associated Bloodstream Infection in Patients With Hematologic Malignancy Receiving Parenteral Nutrition

PURPOSE

Parenteral nutrition (PN) has been shown to be a safe method of feeding in the intensive care unit with modern infection prevention practices, but similar analysis in the hematology-oncology setting is lacking.

METHODS

A retrospective analysis of 1,617 patients with hematologic malignancies admitted and discharged from the Hospital of the University of Pennsylvania during 3,629 encounters from 2017 to 2019 was undertaken to evaluate the association of PN administration with risk of central line-associated bloodstream infection (CLABSI). Proportions of mucosal barrier injury (MBI)-CLABSI and non-MBI-CLABSI were also compared between groups.

RESULTS

Risk of CLABSI was associated with cancer type and duration of neutropenia but not with PN administration (odds ratio, 1.015; 95% CI, 0.986 to 1.045; P = .305) in a multivariable analysis. MBI-CLABSI comprised 73% of CLABSI in patients exposed to and 70% in patients not exposed to PN, and there was no significant difference between groups (χ2 = 0.06, P = .800).

CONCLUSION

PN was not associated with increased risk of CLABSI in a sample of patients with hematologic malignancy with central venous catheters when adjusting for cancer type, duration of neutropenia, and catheter days. The high proportion of MBI-CLABSI highlights the effect of gut permeability within this population.

Evolution of parenteral nutrition practices in a comprehensive cancer center: Comparative audits

INTRODUCTION

Malnutrition affects 20% to 70% of oncology patients depending on the patient's age, type and stage of cancer. Two audits were carried out in 2016 and 2019 to evaluate the practice of Parenteral Nutrition (PN).

METHODS

Records of adult medical inpatients who received PN between January 1, 2018 and April 30, 2019 were retrospectively analysed. Twenty criteria were defined. We conducted a statistical analysis to compare the two audit data.

RESULTS

Between January 1, 2018 and April 30, 2019, 86 hospitalizations with a PN prescription were analysed. Of the 69 patients, 66% were female, the mean and median age was 60 years. These were most often medical oncology patients in palliative care. Gynecological and digestive tumors were the two main tumor localization. Bowel obstruction and palliative care management were the two main reasons for hospitalization. Nutritional assessment, amount of energy prescribed, monitoring, and duration of PN remain with poor results.

CONCLUSION

Our study seems to show improvements in the relevance of PN indications, the prescription, and monitoring in patients due to the computerization of prescription and training of professionals. PN remains often prescribed in exclusive palliative situations. We need to continue our improvements, particularly for the initial clinical and biological assessment, and the monitoring. It requires a referral team to improve management of patients treated with PN.

Early oral feeding after pancreatoduodenectomy: a systematic review and meta-analysis

BACKGROUND

The effect of early oral feeding (EOF) after pancreatoduodenectomy (PD) upon perioperative complications and outcomes is unknown, therefore the aim of this systematic review and meta-analysis was to investigate the effect of EOF on clinical outcomes after PD, such as postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and length of stay (LOS).

METHODS

A systematic review and meta-analysis was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance and assimilated evidence from studies reporting outcomes for patients who received EOF after PD compared to enteral tube feeding (EN) or parenteral nutrition (PN).

RESULTS

Four studies reported outcomes after EOF compared to EN/PN after PD and included 553 patients. Meta-analyses showed no difference in rates of CR-POPF (OR 0.74; 95%CI 0.44-1.24; p = 0.25) or DGE (Grade B/C) (OR 0.83; 95%CI 0.31-2.21; p = 0.70). LOS was significantly shorter in the EOF group compared to the EN/PN group (Mean Difference -3.40 days; 95% -6.11-0.70 days; p = 0.01).

CONCLUSION

Current available evidence suggests that EOF after PD is not associated with increased risk of DGE, does not exacerbate POPF and appears to reduce length of stay.

The Effect of Different Nutritional Nursing Support on the Nutritional Status and Disease Recovery of Elderly Patients with Gastrointestinal Tumors during the Perioperative Period

Objective

This study explored the effect of different nutritional nursing support on nutritional status, immune function, postoperative bowel motility, and complications in elderly patients with gastrointestinal tumors during the perioperative period.

Methods

300 patients with gastrointestinal tumors treated in the Department of Gastroenterology and anorectal surgery of Hangzhou First People's Hospital Affiliated with the Medical College of Zhejiang University from February 2018 to March 2020 were selected as the research objects in this study. Patients were divided into the early enteral nutrition (EEN) and total parenteral nutrition (TPN) groups (150 cases in each group) according to the principle of odd and even admission numbers. The patients in the EEN and TPN groups were given enteral nutrition nursing support and parenteral nutrition nursing support, respectively. The nutritional status, immune function, postoperative bowel motility, and complication rate of the two groups were evaluated 7 days after the operation.

Results

The nutritional indexes decreased 3 days after the operation and gradually recovered 7 days after the operation in both groups with different nutritional nursing support. The Hb, TRF, PAB, and ALB indexes in the TPN group were significantly lower than those in the EEN group (P < 0.01). On the 7th day after the operation, the indexes of peripheral blood immunoglobulin (IgG, IgM, and IgA) were significantly lower than those in the TPN group, and T lymphocyte subsets (CD4, CD8, and CD4/CD8) demonstrated that the immunological indexes of patients in the EEN group were significantly higher than those in the TPN group (P < 0.01). In terms of intestinal peristalsis, the time of first exhaust and first defecation in the EEN group was significantly shorter than that in the TPN group (P < 0.01) during the perioperative period. Furthermore, both groups had different degrees of complications, while patients demonstrated a lower complication rate in the EEN group compared to those in the TPN group, suggesting a safer postoperative mode. The results of subgroup analysis showed that the nutritional indexes of the gastric cancer group 7 days after operation were significantly higher than those of the colorectal cancer group under EEN and TPN nutritional support modes.

Conclusion

Clinical results have suggested that enteral nutrition nursing support can improve the perioperative nutritional status of elderly patients with gastrointestinal tumors by enhancing the immune function and promoting intestinal peristalsis. Meanwhile, the postoperative EEN mode reduces the rate of complications and demonstrates higher safety. Therefore, it has a high clinical application value.

Systematic review of nutrition support interventions in adult haematology and oncology patients receiving CAR T cell therapy

BACKGROUND & AIMS

Chimeric Antigen Receptor (CAR) T cell therapy is a novel adoptive immunotherapy that is revolutionising the treatment of haematological malignancies and solid tumours. Maintaining a patient's nutritional status and implementing nutrition support interventions have been shown to improve certain patient outcomes in standard anti-cancer therapies; however, guidance for nutrition support interventions in CAR T cell therapy are lacking. The primary aim of this review was to determine the impact of nutrition support interventions on patient-centred outcomes for adult CAR T cell therapy haematology and oncology patients. The patient-centred outcomes of interest included nutritional status and dietary intake, morbidity, functional status, and mortality. Our secondary aim was to describe the nutrition implications that have been acknowledged (but not fully evaluated) in CAR T cell therapy, and to guide future research and practice.

METHODS

Four electronic databases (CENTRAL, Embase, MEDLINE and CINAHL) were searched to January 2021, with additional records identified through handsearching and snowballing. Studies considered eligible for inclusion were randomised control trials (RCT), quasi-RCTs, cohort and observational studies, assessing nutrition support interventions (oral, enteral and/or parenteral) in adult haematology and oncology patients receiving CAR T cell therapy or adoptive immunotherapy. No publication status, year or language restrictions were applied.

RESULTS

Two authors reviewed the title and abstracts of 1181 retrieved records; however no studies were eligible for inclusion in this systematic review.

CONCLUSIONS

We are currently unable to identify if there is an association between nutrition support interventions and outcomes in CAR T cell therapy for adults with haematological malignancies or solid tumours. Lower quality clinical studies and animal models were identified that permitted us to qualitatively describe the risks for poor nutritional status in this population. This empty review confirms the need for research into the potential impact of nutrition support in CAR T cell therapy, including well-designed RCTs.

Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted nutrition in patients with advanced cancer

Purpose

The pro vision of clinically assisted nutrition (CAN) in patients with advanced cancer is controversial, and there is a paucity of specific guidance, and so a diversity in clinical practice. Consequently, the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) formed a Subgroup to develop evidence-based guidance on the use CAN in patients with advanced cancer.

Methods

This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials respectively. The outcomes of the review were categorised by the level of evidence, and a “category of guideline” based on the level of evidence (i.e. “recommendation”, “suggestion”, or “no guideline possible”).

Results

The Subgroup produced 11 suggestions, and 1 recommendation (due to the paucity of evidence). These outcomes relate to assessment of patients, indications for CAN, contraindications for CAN, procedures for initiating CAN, and re-assessment of patients.

Conclusions

This guidance provides a framework for the use of CAN in advanced cancer, although every patient needs individualised management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06613-y.

The Contribution of Temporal Flat Lateral Position on the Mortality and Discharge Rates of Older Patients with Severe Dysphagia

Severe dysphagia leads to mortality in older patients and hinders their discharge from hospitals. The temporal flat lateral position (TFLP) enables them to continuously eat, thus resolving the aforementioned issues. We aimed to explore the effect of TFLP on the mortality and discharge rates of older patients with severe dysphagia. This interventional study comprised a historical control of patients admitted to a rural community hospital from January 2019 to December 2020 and diagnosed with severe dysphagia. The primary outcomes included the mortality and the rate of discharge from the hospital. While the intervention group was treated with TFLP, the control group underwent no treatment. We selected 79 participants (intervention group = 26, control group = 53), with an average age of 87.9 years. The discharge rate was significantly higher in the intervention group than in the control group (57.7% vs. 26.4%, p = 0.012). The mortality rate was also significantly lower in the intervention group compared to the control group (34.6% vs. 71.7%, p = 0.003). TFLP can improve the discharge and mortality rates in community hospitals, thereby improving patient outcomes. Clinicians should focus on practical education and the implementation of TFLP in communities in order to promote it.

Clinical nutrition as part of the treatment pathway of pancreatic cancer patients: an expert consensus

Purpose

Malnutrition is a common problem among pancreatic cancer (PC) patients that negatively impacts on their quality of life (QoL) and clinical outcomes. The main objective of this consensus is to address the role of Medical Nutrition Therapy (MNT) into the comprehensive therapeutic management of PC patients.

Methods

A Spanish multidisciplinary group of specialists from the areas of Medical Oncology; Radiation Oncology; Endocrinology and Nutrition; and General Surgery agreed to assess the role of MNT as part of the best therapeutic management of PC patients.

Results

The panel established different recommendations focused on nutritional screening and nutritional screening tools, MNT strategies according to PC status, and MNT in palliative treatment.

Conclusions

There is an unmet need to integrate nutritional therapy as a crucial part of the multimodal care process in PC patients. Health authorities, health care professionals, cancer patients, and their families should be aware of the relevance of nutritional status and MNT on clinical outcomes and QoL of PC patients.

A European survey on the practice of nutritional interventions in head-neck cancer patients undergoing curative treatment with radio(chemo)therapy

PURPOSE

As the practice of nutritional support in patients with head and neck cancer (HNC) during curative radio(chemo)therapy is quite heterogeneous, we carried out a survey among European specialists.

METHODS

A 19-item questionnaire was drawn up and disseminated via the web by European scientific societies involved in HNC and nutrition.

RESULTS

Among 220 responses, the first choice was always for the enteral route; naso-enteral tube feeding was preferred to gastrostomy in the short term, while the opposite for period longer than 1 month. Indications were not solely related to the patient's nutritional status, but also to the potential burden of the therapy.

CONCLUSION

European HNC specialists contextualize the use of the nutritional support in a comprehensive plan of therapy. There is still uncertainty relating to the role of naso-enteral feeding versus gastrostomy feeding in patients requiring < 1 month nutritional support, an issue that should be further investigated.

Cancer cachexia in adult patients: ESMO Clinical Practice Guidelines☆

•This ESMO Clinical Practice Guideline provides key recommendations for managing cancer-related cachexia. •It covers screening, assessment and multimodal management of cancer cachexia. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the author's expert opinion.

Survival of Patients with Multi-Level Malignant Bowel Obstruction on Total Parenteral Nutrition at Home

Home parenteral nutrition (HPN) may improve the survival in selected patients with malignant bowel obstruction. This retrospective, medical registry-based study aimed to identify clinical and laboratory markers predicting short survival, which would allow a more accurate selection of patients that would benefit from HPN in inoperative bowel obstruction. In a retrospective analysis of 114 patients receiving HPN, the median survival was 89 days after discharge home, and the three and six-month survival probability was 48% and 26%, respectively. Parenteral nutrition was provided during 98% of overall survival time and ended on a median of one day before the patient's death. Discontinuing chemotherapy, anemia, severe hypoalbuminemia, and water retention appeared correlated with survival shorter than three months. In these cases, routine initiation of HPN should be discouraged, as it may not bring any benefits to the patient. The decision on the initiation of HPN should be made along with continuing or initiating chemotherapy.

In Reply: Randomized Studies Are Needed to Improve Knowledge of Nutritional Interventions for Advanced Cancer Patients

This letter to the editor continues a discussion about parenteral nutrition for patients with advanced cancer and calls for future randomized studies assessing both enteral and parenteral nutrition.

Development and psychometric testing of a questionnaire to assess Nurse's perception of risks during enteral nutrition

Background

Enteral nutrition (EN) therapy is widely used in clinical practice to provide artificial nutrition to patients, while the incidence of adverse events are relatively highly. In the clinical setting, the occurrence of adverse events is associated with the nurse’s risk perception. Thus, using tool to evaluate nurse’s risk perception of enteral nutrition is necessary.

Methods

The draft questionnaire with 37-items was formed by comprehensive literature reviews and semi-structured in-depth interviews with 11 nurses. Two iterations of expert consultations were used to evaluate the content validity, and 4 items were deleted in this phrase. A 33-items questionnaire was used to survey 352 nurses from five tertiary hospitals in China from May to July 2019 with convenience sampling. Content validity, construct validity and known-groups validity were evaluated by content validity index (CVI), exploratory factor analysis, and the comparisons of the different EN risk perception levels of nurses at different working departments and different educational backgrounds, respectively. Reliability was tested by internal consistency, test-retest reliability, and split-half reliability.

Results

After the exploratory factor analysis, four items were excluded. Finally, the newly developed questionnaire included 29 items explaining 71.356% of the total variance. It consisted of three factors: Risks of operation (15 items); Risks of EN-related adverse events (11 items), and Risks of EN solution selection (3 items). The CVI of the questionnaire was 0.95 and the CVI of items ranged from 0.875–1.0. The results of known-groups validity showed that the nurses with different educational backgrounds had a statistically significant difference of EN risk perception (z = − 3.024, p = 0.002), whereas there was not significantly different between EN risk perception of nurses working in different departments (z = − 1.644, p = 0.100). The Cronbach’s α, test-retest reliability, and split-half reliability of the questionnaire were 0.967, 0.818, and 0.815, respectively.

Conclusions

The newly developed questionnaire for assessing nurse’s EN risk perception showed good reliability and validity. It can be used as a tool for nursing managers to assess Chinese nurses’ EN risk perception ability, so as to help to reduce the occurrence of adverse events during EN implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-020-00520-z.

The effects of nutritional support on selected laboratory parameters in patients with colorectal cancer undergoing surgical resection of the colon

The benefit of the nutritional support provided to patients with colorectal cancer who have undergone the planned resection of the colon in relation to the laboratory markers of nutrition was examined. And it is currently being discussed, that pre-operative optimization of nutritional status reduces the incidence of post-operative complications in cancer patients and regulates selected laboratory parameters. This was a retrospective study where the treatment group (n = 52) received the enteral nutritional support 21 days prior to the scheduled surgery and the other group was formed of patients without preoperative enteral nutrition (n = 52). Laboratory parameters (CRP, leukocytes, albumin, total proteins) were monitored for at least one month before the planned surgery and just before the operation, and the effect of supplemental enteral nutrition on selected laboratory parameters between these two groups was compared. In a group of patients with enteral nutrition, serum albumin levels increased significantly, while CRP was significantly reduced during preoperative enteral nutrition (albumin S-ALB from 35.42 to 37.48, p = 0.0008, C reactive protein from 26.5 to 14.092, p = 0.0007). Nutritional support 21 days prior to surgery in oncological patients resulted in an improvement in laboratory parameters compared to the group of patients without nutritional enteric support. Malnutrition in patients who are candidates for major surgical intervention is a risk factor for postoperative morbidity and mortality. However, further studies are required to verify the effectiveness of this early nutritional intervention on medium and long-term clinical parameters in different types of cancer.